GW1-2022-07099_Well Construction - GW1_20220801

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
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1.Well Contractor Information:
Chris C Russell 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254A so ft- 145 ft.
ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING for molt'cased.rwells OR.LINER if a`HcabI
Russell Well Drilling, Inc FROM TO DIAMETER; THICKNESS MATERIAL
0 ft- 85 ft- 6.25 in. SDR21 JPVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 327636 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft fL in
❑Geothermal(Heating/Cooling Supply) 50Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It- 20 ft Grout Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEL PACK:if applicable)
'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2&DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness,so'Urock e, in size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2]Remarks)
f� o ft. 80 fL Dirt
4.Date Well(s)Completed: 6-2' Well ID# 80 ft- 145 fL ROCk
5a.Well Location: ft. ft
VED
Ashley Plyer Jeremy Plyer ft rt.
Facility/Owner Name Facility ID#(if applicable)
ft. fL -'
408 Shiloh Rd, Statesville, NC 28625 ft. ft. IrlfotntatieZn Proc lJnk
Physical Address,City,and Zip fL ft.
Iredell 21.RFMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field,one lat/long is sufficient) 22.0CMIcation:
35'.74.291' N 080' 82.816' W 7/13/2022
6.Is(are)the well(s): NPermanent or ❑Temporary Signa of Certified well Contractor Date
By signing this form,I hereby certify that,the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: 145 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (ft Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingiover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test:Air
Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13b.Disinfection type: HTH Amount: 1/3 Cup
Revised 6-6-2018
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources